Survey for Participants Currently on PrEP

Qualitative research to understand consumer opinions and preferences for emerging

HIV prevention products among MSM in Atlanta, Houston, and Miami

Attachment 2e: Survey on PrEP

Emerging Prevention Products for MSM

Survey for Participants Currently on PrEP

Form Approved

OMB No: 0920-1091

Exp. Date: 09/30/2021

Privacy Act Statement:

This information is collected under the authority of the Public Health Service Act, Section 301, "Research and Investigation," (42 U.S.C. 241); which discuss authority to maintain data and provide privacy for health research and related activities (42 U.S.C. 242 b, k, and m(d)). This information is also being collected in conjunction with the provisions of the Government Paperwork Elimination Act and the Paperwork Reduction Act (PRA). This information will only be used by the Centers for Disease Control and Prevention (CDC) staff to advance understanding of consumer preferences about emerging biomedical products designed to prevent HIV transmission among men who have sex with men.

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333. Attn: OMB-PRA (0920-1091)

Respondent ID:_______________

Thank you for agreeing to participate in this survey. Your input is very important to us.

STUDY ID NUMBER: _____________

Section 1: Questions about You

D1. How old are you?

_________ years

D2. Which of the following best describe your ethnicity?

1 Hispanic or Latino

0 Not Hispanic or Latino

D3. Which race or races, do you consider yourself to be?

Select all that apply

1 American Indian or Alaska Native

2 Asian

3 Black or African American

4 Native Hawaiian or Other Pacific Islander

5 White

D4. What is your country of birth?

1. United States

2. Other Specify:_________________

D5. What is the highest level of education that you have completed?

1 Less than high school

2 High school diploma or GED

3 Some College, Associate’s Degree, or Technical Degree

4 Bachelor’s/4-year College Degree

5 Any post-graduate degree

D6. Which of the following best represents how you think of yourself?

1 Lesbian or gay

2 Straight, that is not lesbian or gay

3 Bisexual

4 Something else

7 I don’t know the answer

D7. Do you currently have health insurance or health care coverage (including Medicare or Medicaid)?

1 Yes

0 No

7 I don’t know

9 I prefer not to answer

Section 4: Questions about PrEP

P1. In the past 7 days, on how many days did you take your dose of PrEP?

_______ days

P2. If you missed any PrEP doses in the past 7 days, why did you miss your PrEP dose?

Select all that apply

I forgot

I was busy

I didn’t want to take it

My prescription ran out

I didn’t miss any doses

Other. Specify:_________________

P3. Where have you heard about PrEP the most?

Select one response

Sex partners

Friends or family

Health providers or counselors

Sex or dating websites

Other social media (e.g. Facebook, Instagram, Snapchat).

News media

Advertisements around town

Other. Specify: __________________________________

P4. Have you ever stopped taking PrEP on purpose?

0. No (GO TO P6)

1 Yes (GO TO P5)

P5. What was the most important reason you stopped taking PrEP?

Select one response

My insurance wouldn’t cover it

I couldn’t afford it

I decided I didn’t need it for protection anymore

My relationship status changed

I don’t think it worked very well to protect me

I didn’t like the side effects

I was worried about the safety of PrEP

It was too hard taking the pills

My doctor decided to take me off it

I don’t have anybody to prescribe it to me

Other. Specify: __________________________________

P6. Which one of the following statements best reflects your thoughts about taking PrEP in the future.

Select one response

I am planning to continue to use PrEP (END OF SURVEY)

I plan to stop PrEP in the coming weeks (GO TO P7)

I plan to stop taking PrEP in the next 1-5 months (GO TO P7)

I plan to stop taking PrEP in the next 6-12 months (GO TO P7)

I am not sure

P7. If you plan to stop taking PrEP, what is the most important reason for stopping?

Select one response

My insurance doesn’t cover it

I can’t afford it

I don’t think I need it for protection anymore

My relationship status has changed

I don’t think it works very well to protect me

I don’t like the side effects

I am worried about the safety of PrEP

It is too hard taking the pills

My doctor plans to take me off it

I don’t have anybody to prescribe it to me

Other. Specify: __________________________________

Thank you for your valuable input on this survey!